ML20207F966

Responds to NRC Re Violations Noted in Insp Rept 50-298/98-08.Corrective Actions:Circumstances Surrounding Four Examples Have Been Discussed with Individuals Involved & Counseled,Where Appropriate

ML20207F966
Person / Time
Site:	Cooper
Issue date:	03/01/1999
From:	Swailes J NEBRASKA PUBLIC POWER DISTRICT
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
50-298-98-08, 50-298-98-8, NLS990014, NUDOCS 9903110368
Download: ML20207F966 (10)

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H Nebrr.ska Public Power District l

i 4 Nebraska's Energy leader 1

i NLS990014' l March 1,1999 i

i U.S.Nucleir Regulatory Commission i

Attention: Document Control Desk l Washington, D.C. 20555-0001 l

Gentlemen:

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Subject:

- Reply to a Notice of Violation l NRC Inspection Report No. 50-298/98-08 Cooper Nuclear Station, NRC Docket 50-298, DPR-46

Reference:

1. Letter to G. R. Horn (NPPD) from K. E. Brockman (USNRC) dated -  ;

January 22,1999, "NRC Inspection Report 50-298/98-08 and Notice of j Violation" i

.i By letter dated January 22,1999 (Reference 1), the Nuclear Regulatory Commission (NRC) cited

Nebraska Public Power District (District) as being in violation of NRC requirements. This letter, including the attachment, constitutes the District's reply to the referenced Notice of Violation ]

i (NOV) in accordance with 10 CFR 2.201. The District's response to'the NOV was originally due on February 22,1999, however, more time was required to determine the appropriate corrective actions and a submittal date of March 1,1999 was verbally approved by the NRC's Mr. David Loveless in a telephone conversation'with Mr. James Sumpter, Licensing Supervisor, on February 23,1999.

The District accepts the violations and has addressed the ider.tified issues to return Cooper Nuclear Station (CNS) to full compliance.

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We believe that these issues are not indicative of a return to site-wide procedural adherence I problems, which existed previously at CNSi In 1997, we identified a human performance -

I problem manifested by an inadequate level of compliance with written instructions. This was due

- to less than adequate standards 'and a lack of understanding of procedure compliance, as well as

inadequate accountability. -To address procedure compliance, work stand-downs were held and _ jk O {

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Procedure 0.1," Introduction to CNS Operations Manual," was revised to provide improved guidance to the organization on procedure adherence. " Procedure Adherence" was established as

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- a CNS Alignment Issue and an improvement plan was developed and implemented. These actions were successful in raising organizational standards and expectations regarding procedure coopw uuden station .

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- use and compliance. 'In 1998, CNS transitioned from the Procedure Adherence" Alignment Issue i to a more comprehensive approach to improving human performance with the development of i the CNS " Excellence in Human Perfonnance" improvement plan. Rather than limiting focus to ,

procedural compliance, this new approach enables the District to focus attention on those factors leading to excellence in human performance, and to identify and correct factors not leading to  !

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.. excellence, including inadequate written instructions and weaknesses in first line supervision. .!

- Both of these factors were identified by the District as common causes of the examples noted in 'j the first violation, resulting in the failure to fully implement procedural requirements. In the '

evaluation for the second violation, the District concluded that the cause was also a human i performance problem.

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As stated above, the specific details for the violations and their examples are included in the -l attachment to this letter. Should you have any questions conceming this matter, please contact me.

I Sincerely, I

j N i John H. Swa le 1 Vi President ofNuclear Energy )

/Ird I Attachment  !

i cc: Regional Administrator USNRC - Region IV

. Senior Project Manager USNRC -NRR Project Directorate IV-1 1

Senior Resident Inspector l USNRC  !

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i REPLY TO JANUARY 22,1999 NOTICE OF VIOLATION '

COOPER NUCLEAR STATION j

i NRC DOCKET NO. 50-298, LICENSE DPR-46 l

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During NRC inspection activities conducted from November 15 through December 26,1998,  ;

two violations of NRC requirements were identified.

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. The particular violations and the District's reply are set forth below:

A. TechnicalSpecification 5.4.1 requires, inpart, that writtenprocedures be established, d, implemented, andmaintainedthat meet the applicableprocedure.s recommendedin Appendix i A ofNRCRegulatory Guide 1.33. Appendix A ofNRC Regsdatory Guide'1.33 requires l

proceduresfor log entries, equipment control (tagging), replacement and repair of

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recirculation pump seals, and a plantfire protection program.  !

Contrary to the above: l

1. On December 2,1998, NRC inspectors identified that operators did not implement the I

i Procedure 2.0.2, " Operations Logs andReports, " Revision 44,' Step 8.8, requirement that i

the shift supervisor recordino' perable TechnicalSpecification equipment in the Technical l Specifications trackingform. As a result, the operators authorised maintenance on the  !\

reactor equipment cooling system without recognizing or recording that the maintenance . ]

would render the Residual Heat Removal Loop A pumps inoperable.

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2. On December 5, NRC inspectors identified that operators did not impleme.st the \

Procedure 0.9, " Tagging Orders, " Revision 22C3, Step 5.1, requirement is hang and remove tags in a specifiedorder. As a result, operators did not hang tagsfor Valves CS- i 172,, CS-173, and CS-V-14A in the correct order, resulting in the unintentional draining i ofapproximately 1.4 inches ofwaterfrom the reactor. 1 1

3. On December 13, NRC licensee identified that technicians did not implement Step 8.2.38 -

or correctly implement Step 8.2.39 ofProcedure 7.2.5.1, " Reactor Recirculation Pump }

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Seal Cartridge Removal andinstallation, Revision 13. As a result, they incorrectly .  ;

v installed the thrust collar ofthe Reactor Recirculation Pump B seal. The seal i subsequentlyfailed. '

4. - On December 2, NRC inspectors identified that afire watchfailed to implement the

Procedure 0.39, " Fire Watches, " Revision 18, Step 8.1.4, requirement that combustible  ;

materials and openings in walls infloors within 35-foot radius ofhot work be

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protected / covered with noncombustible blankets. Inspectorsfound unprotected \

, combustible material andan opening in thefloor within a 35-foot radius ofthe hot work \

. area.'

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This is a Severity LevelIV violation (Supplement 1) (50-298/98008-01).

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. Admission or Denial to Violation I The District accepts the violation. I Reason for Violation .

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Violation Examples A.1 and A.4 occurred during the same maintenance activity on the Reactor  !

Equipment Cooling (REC) system. The REC system supplies cooling water to the fan coil units ,

for the Residual Heat Removal (RHR) system pumps. In the event that the REC system is inoperable, adequate cooling for one RHR pump is provided with a " stack effect" through an

.i opening in the floor.

l Violation Example A.1 occurred because Procedure 0.39, " Fire ~ Watches" did not provide 1 guidance to adequately address the effect of using fire blankets on the operability of safety i related equipment. Plant conditions at the time of this event required one pump in each loop of 3

RHR to be operable to satisfy Technical Specification Limiting Condition for Operation (LCO) l 3.5.2, Emergency Core Cooling Systems (ECCS)- Shutdown. The work package authorizing .

this activity did not indicate'that the opening in the floor would be partially covered with fire bit.akets to meet the requirements of Procedure 0.39," Fire Watches." The Work Control Center  ;

(WCC) Senior Reactor Operator (SRO) was not aware that this work activity would impact the -)

operability of the RHR pump in the quadrant where the REC maintenance was being performed. .:

Violation Example A.4 was cited for failure to completely cover the opening in the floor in j accordance with the requirements of Procedure 0.39," Fire Watches." Plant postings indicated .l that cosering the floor opening would impact safety system cooling. The maintenance crew leader discussed the concern of RHR pump operability with craft personnel during the' pre-job

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j brief. A' as result, the craft personnel installed a shield in the overhead and placed blankets  !

adjacent to the welding and grinding, only partially covering the floor opening, and a Fire Watch (

. was posted. The maintenance crew leader believed he was meeting the requirements of  !

Procedure 0.39. i

. These two examples (A.1 and A.4) occurred because of a failure of Procedure 0.39 to contain I

. adequate guidance for assessing potential operability impacts and the WCC SRO being unaware

.of the activities being performed.

In the case of Violation Example A.2, Integrated Leak Rate Testing (ILRT) was performed in accordance with Procedure 6.PC.532," Operations Activities for the Primary Containment

Integrated Leak Rate Test," which contains the requirements for tags to be placed. The procedure did _n ot additionally address the applicable requirements of Procedure 0.9," Tagging Orders," and thus did not contain instructions on the order for hanging of tags or positioning of the valves. Therefore, inadequate work instructions caused a failure to properly sequence the I

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Attachment to NLS990014  :

.Page'3 of 7 I series of component manipulations and hanging of tags, which resulted in a 1.4 inch drop in reactor vessel level. The failure to provide ndequate supervisory oversight contributed in that the pre-work briefing did not address the impact of operating the Core Spray Loop "A" valves CS-172, CS-173, and CS-14A in a specific sequence.

L The failure to properly install the Reactor Recirculation pump "B" seal thrust collar (Violation Example A.3) was due to human error, including a lack of appropriate supervisory oversight.

The maintenance team was not adequately prepared to perform this infrequent evolution.1The

installation of the Reactor Recirculation pump "A" seal thrust collar had been successfully

. performed by one maintenance team working with the assistance of a vendor technical representative since a new type of seal was being installed. Procedure steps 8.2.38 and 8.2.39 had been marked ".Not Applicable" ("N/A") as these steps are only required when doing a full I l pump disassembly and are not required when replacing the seal. The same team began the -

installation on Reactor Recirculation pump "B," however a shift change occurred prior to

. completion. The decision was made to continue efforts with a replacement team, without vendor technical assistance, rather than continue with the original team during their next available shift.

Although a tumover brief from the original team was provided, the replacement team had not ,

- been involved with the Reactor Recirculation pump "A" seal installation. The pre-job brief, i required by Procedure 7.0.4, " Conduct of Maintenance," was not adequately perfonned in that-the turnover brief was substituted for the pre-job brief.

The four examples above were evaluated in the aggregate for common causes, and two were

' . identified: 1) inadequate written instructions and 2) inadequate supervisory skills at the first line level.

Corrective Stens Taken and the Results Achieved

1. The circumstances surrounding the four examples have been discussed with the individuals involved, and where appropriate, the individuals were counseled. Operations management j reviewed the events with the appropriate supervision to discuss department roles and i

accountability. Specifically, the WCC SRO who authorized the work on the REC system (Examples _A.1 and A.4) should have been aware of the impacts on RHR operability regardless of procedure adequacy and has been counseled to that effect. - Maintenance management also reviewed the events with the mechanical, electrical, and instrument and  !

control shops, and emphasized standards and expectations in the maimenance area with supervision and crew leaders. Maintensnce supervision, crew leaders, and the specific crew

, . members involved with the REC system events (Examples A.1 and A.4) and the Reactor -

Recirculation pump "B" seal thrust collar installation (Example A.3) were counseled ,

regarding management expectations to stop work if faced with unclear work instructions or j

inadequate pre-job briefings'until a satisfactory resolution is obtained (e.g., a procedure - i revision, training, additional supervisory oversight,' etc.).

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2. The Plant Manager led a discussion with Operations management and supervision, and j Maintenance management, supervision, crew leaders and selected crew members 'on human '

. performance related to the issues identified in the violation examples. Key areas discussed 1

' included communications, management standards and expectations, the role ofleadership m  !

the field to reinforce standards and expectations, error prevention and personal j accountability. The Plant Manager has also initiated weekly meetings with Operations and i Maintenance leadership to focus on communications, standards and expectations, and human performance. ]

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3. : Actions were immediately taken to terminate the lowering ofreactor vessel level due to the incorrect hanging of tags on Core Spray (CS) system valves CS-172, CS-173, and CS-14A )

. (Violation Example A.2). The Control Room directed personnel working'in the drywell to l close Core Spray (CS) valves CS N-172 and CS-V-173, which had been opened for

' performance ofILRT per Procedure 6.PC.532. This terminated the lowering of reactor vessel  ;

level. In addition, immediate actions were taken to assign an individual on each shift (days and nights) to coordinate the performance of 6.PC.532. The procedure was completed ,

without further incident. The individual responsible for the initial writing of 6.PC.532 is no longer employed at Cooper Nuclear Station.' The current procedure owner responsible for the ILRT program was counseled on the failure to specify the order for hanging tags in the procedure consistent with the requirements in Procedure 0.9, " Tagging Orders" (Example j A.2). The operators involved in hanging the tags were also counseled by Operations Management on the failure to adequately implement Procedure 0.9. Procedure 6.PC.532 has also been placed on " Administrative Hold."

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4. Personnel certification for the Reactor Recirculation pump seal replacement was temporarily l

suspended for the individuals involved, which included the job supervisor. Maintenance 1 management also counseled the crew leader regarding his responsibility for supervisory -l oversight in the field. Performance improvement plans have also been put into place for the l crew members involved.  !

Corrective Steos That Will Be Taken to Avoid Further Violations I To address the overall reasons for the violation, the following actions have been established:

1. The District has implemented a plan to improve supervisory and leadership skills for first line supervision, which will specifically_ address accountability and effective communications, and will include examples of Cooper lessons learned. Programs have been established and are cv rently in progress, with r.ctivities planned and supervisors scheduled through 1999, to 'i improve the skills ofincumbent personnel. Implementation.of the plan for the incumbent  !

supervisors will be completed by January 10,2000. .!

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~ 2. ~ A mechanism to collect and disposition feedback from procedure users relative to the quality i

of continuous and reference use procedures will be developed and implemented by April 27, 1999. '

Actions to be taken which will address the specific examples include the following:

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1. - Administrative Procedure 0.39, " Fire Watches," will be revised by May 31,1999 to include i an assessment of fire protection measures for operability impacts on nearby safety related -  ;

equipment during hot work. The assessments will be completed by designated personnel -  ;

.u' sing criteriajointly developed by Operations and the Fire Protection group.

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2. ~ Procedure 0.39 will also be revised by May 31,1999 to allow use of additional Fire Watches  ;

- for fire protection of adjacent combustibles as an alternative to fire blankets or other non- .

' combustible shields to provide flexibility when equipment operability may be impacted

-(Examples A.1 and A.4). '

3. Procedure 6.PC.532 will be revised to group the valves in both attachments by system and to  ;

specify an' order for valves to be positioned (Example A.2) prior to the next required -

performance (Refueling Outage 20). >

i Date When Full'Comoliance Will Be Achieved j The District is in full compliance regarding the identified violation.

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'B. 10 CFR Part 50, Appendix B,' Criterion XVI, requires, inpart, that measures shall be .

. established to assure that conditions adverse to quality, such asfailures, malfunctions,  :

deficiencies, deviations, defective material and equipment, and nonconformances are l promptly identified and corrected. In the case ofsigm*ficant conditions adverse to quality, the measures shall assure that the cause ofthe condition is determined and that corrective actions will be taken topreclude repetition.

• Contrary to the above, the licenseefailed to take efective measures to preclude repetition of inadvertent opening ofthe torus-to-drywell vacuum breaker documented in Licensee Event l

Repw:t 50-298/97-007,'" Opening ofa torus-to-drywell vacuum breaker. " Specifically, the; }

licenseefailed to take reasonable action to prevent inadvertent opening ofthe vacuum l

^breakt.rpr all conditions that couldreasonably be expected, as documented in procedures l

, f . anddesign documents. '

This is a Severity LevelIV violation (Supplement 1) (50-298/98008-02).

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Page'6 of 7 Admission or Denial to Violation -  ;

The District accepts the violation. 1

,a Reason for Violation j

= .l The cause of this ineffective corrective action was human error in that the individual who revised 'I

. Procedure 2.2.60, " Primary Containment Cooling and Nitrogen Inerting System," did not j perform sufficient in-depth research prior to revising the procedure.

i f- i f 'Although the initial procedure revision did not accurately reflect values which bound possible .

l plant conditions, it should be noted that no inadvertent actuation of torus-to-drywell vacuum  !

breakers have occurred since Licensee Event Report (LER) 1997<007. Theinadvertent actuation j of the vacuum breakers reported in LER 1997-007 was classified as having low safety  :

significance. ' However, the District agrees that the procedure did require revision to ensure j sufficient guidance existed to alert operators of the potential for this actuation. The procedure  ;

was also revised to include available design information in order to minimize the possibility of - j recurrence. -  ;

Corrective Steos Taken and the Results Achieved i

1. . The caution statements in Procedure 2.2.60," Primary Containment Cooling and Nitrogen Inenmg System" were revised to incorporate the Updated Safety Analysis Report (USAR) ~ d minimum value at which the torus-to-drywell vacuum breakers may open. The procedural j limit for torus-above-drywell pressure has also been lowered to the USAR value. )

- 2. This event has been discussed with the individual that perfonned the initial procedure  ;

revision. The individual is now aware that the values referenced in the caution statement did j

. not reflect actual plant values, and that the procedure has since been revised. The individual l recognized the impact that his failure to perform in-depth research for the procedure change. j

' had relative to this issue during a discussion of the violation with the Plant Manager.'

3. Administrative Procedure 0.4A, Procedure Change Process Supplement, has been revised to require performance of Verifiestion/ Validation for changes to operational values or limits in .]

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-procedures, if such changes have not already received some type of formal review.

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'E ' Corrective Ster,s That Will Be Taken to Avoid Further Violations j

1. Operations Management will provide lessons leamed (tailgate) to Operations personnel l regarding the torus-to-drywell vacuum breaker issue and the subject ofineffective corrective l

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• actions. -Emphasis will be given on the need to thoroughly investigate issues prior to implementing corrective actions. This will be completed by March 31,1999.

2. Site personnel will be made aware of the torus-to-drywell vacuum breaker issue, along with the common theme ofineffective corrective actions, by inclusion in the site newsletter. This will be completed by April 12,1999.

Date When Full Comoliance Will Be Achieved

. The District is in full compliance regarding this violation. ,

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e LIST OF NRC COMMITMENTS Corr'espondence No: NLS990034 The following table identifies these actions committed to by the District in this document. Any other actions discussed in the submittal represent intended or planned actions by the District. They are described to the NRC for the NRC's informatior, and are not regulatory commitments. Please notify the NL&S Manager at Cooper Nuclear Station of any questions regarding this document or any associated regulatory commitments.

COMMITMENT COMMITTED DATE OR OUTAGE The District has implemented a plan to improve supervisory and leadership skills for January 10,2000 first line supervision, which will specifically address accountability and effective communications, and will include examples of Cooper lessons leamed. Programs have been established and are cur ently in progress, with activities planned and supervisors scheduled through 1999, to improve the skills ofincumbent personnel.

i Implementat on of the plan for the incumbent supervisors v.nll be completed by January 10,2000 1 A mechanism to collect and disposition feedback from procedure users relative to the April 27,1999 quality of continuous and reference use procedures will be developed and implemented by April 27,1999.

Administrative Procedure 0.39," Fire Watches, will be revised by May 31,1999 to May 31,1999 include an assessment of fire protection measures for operability impacts on nearby safety related equipment during hot work. The assessments will be completed by designated personnel us~mg criteriajointly developed by Operations and the Fire Protection group.

Procedure 0.39 be revised by May 31,1999 to allow use of additional Fire Watches May 31,1999 for fire protection of adjacent combustibles as an alternative to fire blankets or other non-combustible shields to provide flexibility when equipment operability may be japacted.

Procedure 6.PC.532 will be revised to group the valves in both attachments by system August 31,2000 and to specify an order for valves to be positioned (Example A.2) prior to the next required performance (Refueling Outage 20).  ;

Operations Management will provide lessons learned (tailgate; to Operations March 31,1999 personnel regarding the torus-to-drywell vacuum breaker issue and the subject of ineffective corrective actions. Emphasis will be given on the need to thoroughly investigate issues prior to implementing corrective actions. This will be completed by March 31,1999. I Site personnel will be rr.ade aware of the torus-to-drywell vacuum breaker issue, along April 12,1999 with the commsn theme of ineffective corrective actions, by inclusion in the site newsletter. This will be completed by April 12,1999.

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